5123:2-9-06
Home and community-based services waivers - documentation and payment for services under the individual options and level one waivers.

This rule establishes standards governing documentation and
payment for home and community-based services under the individual options
waiver and level one waiver components of the medicaid program that the Ohio
department of developmental disabilities administers pursuant to section
5166.21 of the Revised
Code.

(1)
"Agency provider" means an entity that
directly employs at least one person in addition to the
chief executive officer for the purpose of providing services for which
the entity must be certified in accordance with rule
5123:2-2-01 of the
Administrative Code.

(2)
"Cost projection and payment authorization" means the process followed and the
form used by county boards (including the payment authorization for waiver
services) to communicate the frequency, duration, scope, and amount of payment
requested for each home and community-based service that is identified in the
individual service plan.

(3)
"Cost
projection tool" means the web-based analytical tool, developed and
administered by the department, used to project the cost of home and
community-based services identified in the individual service plans of
individuals enrolled in individual options and level one waivers. The
department shall publish any changes to the cost projection tool thirty
calendar days prior to implementation.

(4)
"County board" means a county board of
developmental disabilities.

(6)
"Fifteen-minute billing unit" means a
billing unit that equals fifteen minutes of service delivery time or is greater
or equal to eight minutes and less than or equal to twenty-two minutes of
service delivery time.

(7)
"Funding
range" means one of the dollar ranges contained in appendix A to this rule to
which individuals enrolled in the individual options waiver have been assigned
for the purpose of funding services other than adult day support,
career planning, group employment support, individual
employment support,non-medical transportation, vocational habilitation, and waiver nursing services. The funding range
applicable to an individual is determined by the score derived from the Ohio
developmental disabilities profile that has been completed by a county board
employee qualified to administer the tool.

(8)
"Guardian" means a guardian appointed by
the probate court under Chapter 2111. of the Revised Code. If the individual is
a minor, "guardian" means the individual's parents. If no guardian has been
appointed for a minor under Chapter 2111. of the Revised Code and the minor is
in the legal or permanent custody of a government agency or person other than
the minor's natural or adoptive parents, "guardian" means that government
agency or person. "Guardian" includes an agency under contract with the
department for the provision of protective service in accordance with sections
5123.55 to
5123.59 of the Revised
Code.

(9)
"Home and community-based
services" has the same meaning as in section
5123.01 of the Revised
Code.

(10)
"Independent provider"
means a self-employed person who provides services for which he or she must be
certified in
accordance with rule
5123:2-2-01 of the
Administrative Code and does not employ, either directly or through contract,
anyone else to provide the services.

(11)
"Individual" means a person with a
developmental disability or for purposes of giving, refusing to give, or
withdrawing consent for services, his or her guardian in accordance with
section 5126.043 of the Revised Code or
other person authorized to give consent.

(12)
"Individual funding level" means the
total funds, calculated on a twelve-month basis, that result from applying the
payment rates in service-specific rules in Chapter 5123:2-9 of the
Administrative Code to the units of all waiver services other than adult day
support, career planning, group employment support,
individual employment support, non-medical transportation,
vocational habilitation, and waiver nursing services established by the
individual service plan development process to be sufficient in frequency,
duration, and scope to meet the health and welfare needs of an individual
enrolled in the individual options waiver. Unless prior authorization has been
obtained in accordance with rule
5123:2-9-07 of the
Administrative Code, the individual funding level for services paid in
accordance with this rule shall be within or below the funding range assigned
to the individual as the result of administration of the Ohio developmental
disabilities profile.

(13)
"Individual service plan" means the written description of services, supports,
and activities to be provided to an individual developed in accordance with
rule 5123:2-1-11 of the
Administrative Code.

(14)
"Natural
supports" means the personal associations and relationships typically developed
in the community that enhance the quality of life for individuals. Natural
supports may include family members, friends, neighbors, and others in the
community or organizations that serve the general public who provide voluntary
support to help an individual achieve agreed upon outcomes through the
individual service plan development process.

(15)
"Ohio developmental disabilities
profile" means the standardized instrument used by the department to assess the
relative needs and circumstances of an individual enrolled in the individual
options waiver compared to others. The individual's responses are scored and
the individual is linked to a funding range, which enables similarly situated
individuals to access comparable waiver services paid in accordance with rules
adopted by the department.

(16)
"Prior authorization" means the process to be followed in accordance with rule
5123:2-9-07 of the
Administrative Code to authorize an individual funding level for an individual
enrolled in the individual options waiver that exceeds the maximum value of the
funding range.

(a)
Is certified by the department to provide
home and community-based services; and

(b)
Has a medicaid provider agreement with
the Ohio department of medicaid.

(18)
"Service and support administrator"
means a person, regardless of title, employed by or under contract with a
county board to perform the functions of service and support administration and
who holds the appropriate certification in accordance with rule
5123:2-5-02 of the
Administrative Code.

(19)
"Service
documentation" means all records and information on one or more documents,
including documents that may be created or maintained in electronic software
programs, created and maintained contemporaneously with the delivery of
services, and kept in a manner as to fully disclose the nature and extent of
services delivered that shall include the items delineated in service-specific
rules in Chapter 5123:2-9 of the Administrative Code to validate payment for
medicaid services.

(20)
"Team" has
the same meaning as in rule
5123:2-1-11 of the
Administrative Code.

(21)
"Three-year period" means the three-year period beginning with the individual's
initial enrollment date and ending three years later. Subsequent three-year
periods begin with the ending date of the previous three-year period and end
three years later.

(22)
"Waiver
eligibility span" means the twelve-month period following either an
individual's initial enrollment date or a subsequent eligibility
re-determination date.

(1)
Individuals enrolled in the individual
options waiver shall be assigned to a funding range based on completion and
scoring of the Ohio developmental disabilities profile and the
cost-of-doing-business category that applies to the county in which the
individual receives the preponderance of services. The funding ranges are
contained in appendix A to this rule. The cost-of-doing-business categories are
contained in appendix B to this rule.

(f)
Any other variable that
significantly impacts the individual's needs as determined by the department
through statistical analysis.

(3)
The service and support administrator
shall ensure that an Ohio developmental disabilities profile is completed with
input from the individual and the team.

The service and support administrator shall inform the
individual, and the team with consent of the individual, of the assigned
funding range at the time of enrollment and any time the Ohio developmental
disabilities profile is reviewed or updated. The service and support
administrator shall ensure the individual, and the team with consent of the
individual, have access to review the Ohio developmental disabilities profile
and other assessments used in relation to completion of the Ohio developmental
disabilities profile.

(4)
Following assignment of a funding range, an individual service plan that
assures the individual's health and welfare shall be reviewed, revised, or
developed with the individual. The service and support administrator shall
ensure that individuals share services to whatever extent practical and with
the agreement of the team. Paid services should be used in conjunction with
available natural supports. The service and support administrator shall ensure
that development or revision of the individual service plan addresses the
availability of natural supports that currently exist or could be developed to
meet assessed needs, including:

(b)
Supports that
friends, neighbors, and others in the community provide.

(5)
The county board shall apply rates for
the units of each waiver service, other than adult day support,
career planning, group employment support, individual
employment support, non-medical transportation,
vocational habilitation, and waiver nursing services, resulting from
completion of the individual service plan development process to calculate the
individual funding level.

(6)
The
county board shall determine whether the individual funding level is within,
exceeds, or is below the assigned funding range for the individual. The service
and support administrator shall inform the individual of this determination in
accordance with procedures developed by the department.

(7)
When an individual service plan is
revised and a new funding level is determined, the providers of waiver services
to the individual shall verify to the county board the number of units of each
waiver service delivered during the individual's current waiver eligibility
span so that the county board may accurately calculate the number of units of
services available for the individual's use during the remainder of the waiver
eligibility span.

(8)
The county
board shall complete the cost projection and payment authorization and the
service and support administrator shall ensure waiver services are initiated
for an individual whose funding level is within the funding range determined by
the Ohio developmental disabilities profile. The service and support
administrator shall inform the individual in writing and in a form and manner
the individual can understand of the individual's due process rights and
responsibilities as set forth in section
5160.31 of the Revised
Code.

(a)
The county board shall inform the
individual of the individual's right to request prior authorization to obtain
services that result in an individual funding level that exceeds the funding
range using the process described in rule
5123:2-9-07 of the
Administrative Code.

(b)
If,
through the prior authorization process, the request for the funding level is
approved, the county board shall ensure the cost projection and payment
authorization is completed and waiver services are initiated.

(c)
If, through the prior authorization
process, the request for the funding level is denied, the service and support
administrator shall continue the individual service plan development process to
determine if an individual service plan that assures the individual's health
and welfare can be developed within the individual's funding range.

(i)
If an individual service plan that meets
these conditions is developed, the county board shall ensure the cost
projection and payment authorization is completed and waiver services are
initiated.

(ii)
If an individual
service plan that meets these conditions cannot be developed, the county board
shall propose to deny the individual's initial or continuing enrollment in the
waiver and inform the individual of the individual's due process rights and
responsibilities as set forth in section
5160.31 of the Revised
Code.

(10)
The department shall use the twelve-month period following either an
individual's initial enrollment date or a subsequent eligibility
re-determination date to verify that cumulative payments made for waiver
services remain within the approved funding range for each individual or that
cumulative payments made for waiver services remain within the approved funding
range when prior authorization has been granted.

(11)
The department shall periodically
re-examine the scoring of the Ohio developmental disabilities profile and the
linkage of the scores to the funding ranges.

(1)
Under the level one waiver, payment
for community respite, homemaker/personal care, informal respite,
money management, residential respite, and
transportation, alone or in combination, shall not exceed five thousand three
hundred twenty-five dollars per waiver eligibility span.

(3)
In accordance with rule
5123:2-9-27 of the
Administrative Code, payment for emergency assistance under the level one
waiver shall not exceed eight thousand five hundred twenty dollars within a
three-year period.

(1)
The individual funding level may increase
or decrease based on the outcome of the individual service plan development
process. In no instance shall the individual funding level exceed the cost cap
approved for the waiver in which the individual is enrolled. The county board
has the authority and responsibility to make changes to individual funding
levels which result from the individual service plan development process in
accordance with paragraph (C) of this rule. Changes to individual funding
levels are subject to review by the department.

(2)
A funding range established for an
individual shall change only when changes in assessment variable scores on the
Ohio developmental disabilities profile justify assignment of a new funding
range. Any or all Ohio developmental disabilities profile variables may be
revised at any time at the request of the individual or at the discretion of
the service and support administrator, with the individual's
knowledge.

(3)
Neither the
department nor the county board shall recommend a change in individual funding
level within the funding range or assign a new funding range after notification
that the individual has requested a hearing pursuant to section
5160.31 of the Revised Code
concerning the approval, denial, reduction, or termination of
services.

(1)
In situations where more than one
staff member serves more than one individual simultaneously, the individuals'
needs and circumstances shall determine staffing ratios, based on a unit of one
staff to the portion of the total group that includes the individual. Only when
it is impractical to determine staff ratios based on a unit of one staff, the
provider shall, as authorized in the individual service plan, use the
applicable service codes and payment rates established in service-specific
rules in Chapter 5123:2-9 of the Administrative Code to indicate both staff
size and group size.

(2)
Staffing
ratios do not change at times when one or more individuals, for whom the staff
is responsible, are not physically present, but are within verbal, visual, or
technological supervision of the staff providing the service. Technological
supervision includes staff contact with individuals through telecommunication
and/or electronic signaling devices.

(1)
Prior to the beginning of an
individual's waiver eligibility span, the individual's service and support
administrator or other county board designee shall prepare a projection of the
annual cost of every individual options or level one waiver service that is
authorized in the individual service plan for the waiver eligibility span using
the cost projection tool.

(2)
The
cost projection shall be based on staffing ratios and the total estimated
number of service units the individual is expected to receive in accordance
with his or her individual service plan during the waiver eligibility span.
Staffing ratios contained in the cost projection tool shall be considered a
part of the individual service plan.

(3)
The total number of service units shall
be determined with input from the individual and his or her team as part of the
individual service plan development process.

(4)
The cost projection tool shall project
the cost of services based on the payment rates established in service-specific
rules in Chapter 5123:2-9 of the Administrative Code.

(6)
The cost projection tool shall be used to
project costs based on medicaid payment rates for individuals, regardless of
funding source, who share services with individuals enrolled in home and
community-based services waivers.

(7)
The individual's provider shall have
access to the cost projection tool including, but not limited to, the detail
and summary information. At the request of the individual, other persons shall
have access to the detail and summary information in the cost projection
tool.

(8)
When changes occur that
the team determines affect the service
authorization, the county board shall enter changes to the cost
projection tool within ten calendar days of a
recommendation from the team to change the service authorization. These
changes shall be made along with any necessary revisions to the individual
service plan, daily rate application, and prior authorization request
(as applicable) for the individual or individuals affected by the
changes.

(9)
County boards shall
complete a cost projection using the cost projection tool when an individual is
initially enrolled in an individual options or level one waiver and when an
individual is annually re-determined eligible for continued enrollment in an
individual options or level one waiver. The cost projection tool shall be the
only authorized cost projection instrument.

(1)
Providers shall maintain service
documentation in accordance with this rule and service-specific rules in
Chapter 5123:2-9 of the Administrative Code.

(2)
Invoices a provider submits to the
department for payment for services delivered shall not be considered service
documentation. Any information contained in the submitted invoice may not and
shall not be substituted for any required service documentation information
that a provider is required to maintain to validate payment for medicaid
services.

(3)
Each provider shall
maintain all service documentation in an accessible location. The service
documentation shall be made available upon request for review by the
department, the Ohio department of medicaid, the centers for medicare and
medicaid services, a county board or regional council of governments that
submits to the department payment authorization for the service, and those
designated or assigned authority by the department or the Ohio department of
medicaid to review service documentation.

(4)
When a provider discontinues operations,
the provider shall, within seven calendar days, notify the county boards for
the counties in which individuals for whom the provider has provided services
reside, of the location where the service documentation will be stored, and
provide the county board with the name and telephone number of the person
responsible for maintaining the service documentation.

(1)
Providers shall be paid the lesser of
their usual and customary rate or the payment rate for each waiver service that
is delivered. The department shall establish a mechanism through which
providers shall communicate their usual and customary rates to the department.
A single provider may charge different usual and customary rates for the same
service when the service is provided in different geographic areas of the
state. In this instance, the usual and customary rates charged shall be
declared for each cost-of-doing-business category contained in appendix B to
this rule that identifies the counties in which the provider intends to provide
specific services. Upon notification of a provider's usual and customary rate
or change in usual and customary rate, the department shall provide notice to
the appropriate county board.

(2)
The billing units, service codes, and payment rates for waiver services are
contained in service-specific rules in Chapter 5123:2-9 of the Administrative
Code including, but not limited to:

(a)
5123:2-9-13 (career planning under the individual
options and level one waivers);

(b)
5123:2-9-14
(vocational habilitation under the individual options and level one
waivers);

(c)
5123:2-9-15 ( individual employment
support under the individual options and level one waivers);

(d)
5123:2-9-16 ( group employment support under the individual
options and level one waivers);

(e)
5123:2-9-17 (adult
day support under the individual options and level one waivers);

(f)
5123:2-9-18 (non-medical transportation under the individual options and level
one waivers);

(g)
5123:2-9-20 (money management under the individual
options and level one waivers);

(3)
The department shall
periodically collect payment information for a comprehensive, statistically
valid sample of individuals from providers of home and community-based services
at the time the information is collected. Based upon the department's review of
the information, the department shall recommend to the Ohio department of
medicaid any changes necessary to assure that the payment rates are sufficient
to enlist enough waiver providers so that waiver services are readily available
to individuals, to the extent that these types of services are available to the
general population, and that provider payment is consistent with efficiency,
economy, and quality of care.

(4)
Payment for home and community-based services constitutes payment in full.

(1)
When home and
community-based services are also available on the medicaid state plan, state
plan services shall be billed first. Only home and community-based services in
excess of those covered under the medicaid state plan shall be
authorized.

(2)
Claims for payment
for home and community-based services shall be submitted to the department in
the format prescribed by the department. The department shall inform county
boards of the billing information submitted by providers in a manner and at a
frequency necessary to assist county boards to manage the waiver expenditures
being authorized.

(3)
Claims for
payment shall be submitted within three hundred fifty calendar days after the
home and community-based services are provided. Payment shall be made in
accordance with the requirements of rule
5160-1-19 of the Administrative
Code. Claims for payment shall include the number of units of
service.

(4)
All providers of home
and community-based services shall take reasonable measures to identify any
third-party health care coverage available to the individual and file a claim
with that third party in accordance with the requirements of rule
5160-1-08 of the Administrative
Code.

(5)
For individuals with a
monthly patient liability for the cost of home and community-based services, as
defined in rule 5160:1-3- 04.3 of the Administrative Code, and
determined by the county department of job and family services for the county
in which the individual resides, payment is available only for the home and
community-based services delivered to the individual that exceed the amount of
the individual's monthly patient liability. Verification that patient liability
has been satisfied shall be accomplished as follows:

(a)
The department shall, on a monthly basis,
provide notification to the appropriate county board identifying each
individual who has a patient liability for home and community-based services
and the monthly amount of the patient liability.

(b)
The department shall determine the home
and community-based services to which each individual's patient liability shall
be applied and assign the corresponding monthly patient liability amount to the
home and community-based services provider that provides the preponderance of
home and community-based services. The county board shall notify each
individual and home and community-based services provider, in writing, of this
assignment.

(c)
Upon submission of
a claim for payment, the designated home and community-based services provider
shall report the home and community-based services to which the patient
liability was assigned and the applicable patient liability amount on the claim
for payment using the format prescribed by the department.

(6)
The department, the Ohio department of
medicaid, the centers for medicare and medicaid services, and/or the auditor of
state may audit any funds a provider of home and community-based services
receives pursuant to this rule, including any source documentation supporting
the claiming and/or receipt of such funds.

(7)
Overpayments, duplicate payments,
payments for services not rendered, payments for which there is no
documentation of services delivered or for which the documentation does not
include all of the items required in service-specific rules in Chapter 5123:2-9
of the Administrative Code, or payments for services not in accordance with an
approved individual service plan are recoverable by the department, the Ohio
department of medicaid, the auditor of state, or the office of the attorney
general. All recoverable amounts are subject to the application of interest in
accordance with rule
5160-1-25 of the Administrative
Code.

(8)
Providers of home
and community-based services shall maintain the records necessary and in such
form to disclose fully the extent of home and community-based services
provided, for a period of six years from the date of receipt of payment or
until an initiated audit is resolved, whichever is longer. The records shall be
made available upon request to the department, the Ohio department of medicaid,
the centers for medicare and medicaid services, and/or the auditor of state.
Providers who fail to produce the records requested within thirty calendar days
following the request shall be subject to decertification and/or loss of their
medicaid provider agreement.

(1)
Applicants for and recipients of waiver
services administered by the department may use the process set forth in
section 5160.31 of the Revised Code and
rules implementing that statute for any purpose authorized by that statute. The
process set forth in section
5160.31 of the Revised Code is
available only to applicants, recipients, and their lawfully appointed
authorized representatives. Providers shall have no standing in an appeal under
that section.

(2)
Applicants for
and recipients of waiver services administered by the department shall use the
process set forth in section
5160.31 of the Revised Code and
rules implementing that statute for any challenge related to the administration
and/or scoring of the Ohio developmental disabilities profile or to the type,
amount, level, scope, or duration of services included in or excluded from an
individual service plan or behavioral support strategy. A change in staff to
waiver recipient service ratios does not necessarily result in a change in the
level of services received by an individual.

The Ohio department of medicaid retains final authority to
establish funding ranges for waiver services; to establish payment rates for
waiver services; to review and approve each service identified in an individual
service plan that is funded through a home and community-based services waiver;
and to authorize the provision of and payment for waiver services through the
cost projection and payment authorization.